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Trauma
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DEMO PROTOTYPE INTAKE FORM
First Name
Last Name
Date of incident
Date of intake
Accessibility Requirement
Yes
No
Language
English
French
Other
ASL
Translator Required
Time of Intake / Referral
8AM-4:59PM
5PM-11:59PM
12:00AM-7:59AM
N/A
Source of Referral
Leeds OPP
Grenville OPP
Gananoque Police
Brockville Police
VWAP
Interval House
CAS
TISS
BCI
South Grenville
ARCC
Probation
Fire
EMS
Indigenous Organization
Other VS
Self
Other
Name of Referral Source
Method of Contact by Referral Source
Pager
Telephone
Police Database
Office Walk-in
Online Channel
Incident Crime Type
Abduction and Kidnapping
Assault (not DV-related)
Break & Enter
Child Abuse
Criminal Harassment
Domestic Violence
Elder Abuse
Hate Crime
Homicide
Human Trafficking
Motor Vehicle Collisions (Crime-Related)
Robbery
Sexual Violence
Sudden Death
Suicide
Theft/Fraud
Vandalism
Fire
Other Crime-Related Occurrence
Tragic Circumstance
Mental Health
Intake within 72 hours of incident
Yes
No
New Client
Yes
No
New Incident
Yes
No
Gender
Male
Female
Age (adult / youth / child / senior acceptable if age not known)
Address
Home Phone
Cell Phone
Work Phone
Other
Follow-up Specifics
Additional Clients
Additional Client That May be Involved
Age of Additional Client
Senior
Adult
Youth
Child
Gender of Additional Client
Male
Female
Additional Client That May be Involved
Age of Additional Client
Senior
Adult
Youth
Child
Gender of Additional Client
Male
Female
Additional Client That May be Involved
Age of Additional Client
Senior
Adult
Youth
Child
Gender of Additional Client
Male
Female
Additional Client That May be Involved
Age of Additional Client
Senior
Adult
Youth
Child
Gender of Additional Client
Male
Female
Additional Client That May be Involved
Age of Additional Client
Senior
Adult
Youth
Child
Gender of Additional Client
Male
Female
Immediate Family
Immediate Family Member
Immediate Family Member Age
Senior
Adult
Youth
Child
Immediate Family Member Gender
Male
Female
Immediate Family Member
Immediate Family Member Age
Senior
Adult
Youth
Child
Immediate Family Member Gender
Male
Female
Immediate Family Member
Immediate Family Member Age
Senior
Adult
Youth
Child
Immediate Family Member Gender
Male
Female
Immediate Family Member
Immediate Family Member Age
Senior
Adult
Youth
Child
Immediate Family Member Gender
Male
Female
Other Witnesses
Other Witness
Other Witness Age
Senior
Adult
Youth
Child
Other Witness Gender
Male
Female
Other Witness
Other Witness Age
Senior
Adult
Youth
Child
Other Witness Gender
Male
Female
Other Witness
Other Witness Age
Senior
Adult
Youth
Child
Other Witness Gender
Male
Female
Other Witness
Other Witness Age
Senior
Adult
Youth
Child
Other Witness Gender
Male
Female
Synopsis of Call
Needs Assessment
Previous traumatic experience
Estranged from family
Socially and/or physically isolated
No identified residence of their own
No income or lacking financial support
disability - physical
disability - cognitive
disability - psychiatric
Unable / unwilling to connect with community resources
Alcohol / drug related challenges
Current legal issues (criminal / family / immigration)
Medical challenges
Youth
Elderly
Have children in the home
Any immediate safety needs
Any non-immediate safety needs
Current or past domestic violent relationship
Residing in an unsafe environment
Suicidal thoughts / plan
Team Leader on Duty
Sarah
Patti
Laura
Sonya
Alyssa
Amanda
Response Team Member (if different from TL on duty)
Staff Assigned
Sarah
Collette
Laura
Patti
Alyssa
Amanda
Emergency Resources Required / VQRP
Home Safety
Cell Phone
Transportation
Lodging
Clean up
Funeral
Emergency Resources Required - Interval House
Shelter
Accompaniment/Transportation
File Open or Closed
Open
Closed
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